Are lessons learned?

Are lessons learned? SISG 13 October 2003

Some facts SISG 13 October 2003

Aircraft A Aircraft B • High traffic demand/ limited RWY capacity • High traffic demand/ limited RWY capacity • Bad weather at destination • Bad weather at destination • ATC unable to communicate delay figures • ATC unable to communicate delay figures • Lack of appreciation by ATC of the fuel situation due to communications deficiencies • Lack of appreciation by ATC of the fuel situation due to communications deficiencies • Decision of pilot not to divert to alternate due to possible heavy traffic • Decision of pilot not to divert to alternate due to possible heavy traffic • Inappropriate handling of the aircraft by ATC • Inappropriate handling of the aircraft by ATC • Total Holding time 1h17 mins • Total Holding time 0h56 mins SISG 13 October 2003

x AircraftA AircraftB • Aircraft A landed with 800kg of fuel • Aircraft B had to go around due to windshear and could not reach the airport • This incident took place in year X+9 • This accident took place in year X SISG 13 October 2003

The probable cause SISG 13 October 2003

Training ATFM Overload? Training OPS mgt Staff plan Staff? APP unable to work out and/or communicate EATs ATM did not provide information about delay Lack of support ? Training OPS mgt Staff plan Procedures Hand over? Pilot decision not to divert Equipment? Decisive factor Failure Design Pilot announcement of fuel situation as per company SOPs Aggravating factors ATM holding (s) ATM wrong appreciation of the fuel situation Communication deficiencies ATCOs aware of these provisions? (APP) ATC Manual identical to company SOPs ATM speed reduction ICAO « minimum fuel » not in State Regulations ATM long vectoring Acft lands short of fuel or Crashes SISG 13 October 2003

The failure of the flightcrew to adequately manage the airplane’s fuel load Note: that includes the decision not to divert • The failure of the flightcrew to communicate an emergency situation • Inadequate traffic flow management (B only)(A?) • Lack of understandable phraseology for pilots and controllers for minimum and emergency fuel states • Crew fatigue (B only) • Windshear (B only) • The failure by ATC to inform the flightcrew of additional holding • The failure by ATC to co-ordinate between sectors the remark of the flightcrew concerning their fuel situation (B only)(A?) • The failure by ATC to transmit the RVR and latest windshear to the flightcrew (B only) SISG 13 October 2003

The recommendations SISG 13 October 2003

Develop in co-operation with the International Civil Aviation Organisation a standardised glossary of definitions, terms words and phrases to be used that are clearly understandable to both pilots and air traffic controllers regarding minimum and emergency fuel communications. B That the CAA, in co-operation with the JAA, defines the message “minimum fuel” together with associated procedures and that the phraseology relating to this procedure foresees the announcement by the pilot of the remaining flight time. A 9 years later almost the same recommendation is made by another AAIB not addressed not (satisfactorily) addressed not implemented SISG 13 October 2003

Aircraft operators should remind their flight crews that in general they will not obtain an EAT from an en-route ATC centre A That it is added to the phraseology a standard message enabling ATCOs to reply concisely and in a definitive manner to requests that are beyond their remit. A SISG 13 October 2003

That the CAA, in co-operation with the JAA, defines the criteria allowing to convert diversion fuel in holding, and that the CAA issues an SOP prior to the modification of the JAR -OPS if deemed necessary. A So was the procedure used a national regulation ? company regulation? SISG 13 October 2003

Incorporate into air route traffic control centres equipment to provide a recorded broadcast of traffic management information that can be monitored by all aircraft within each center’s boundaries to provide pilots of early indications of potential delays en-route. B B SISG 13 October 2003

Immediately notify all domestic and foreign air carriers to emphasise that all pilots operating commercial air transport flights through the (…) national airspace must be thoroughly knowledgeable of the flight operating and air traffic control rules and procedures, including standard phraseology. B SISG 13 October 2003

Conduct a comprehensive study of the ATFM facility and ATM system, to determine the effectiveness and appropriateness of training, responsibilities, procedures and methods of application for the ATM system. B SISG 13 October 2003

Immediately issue a general notice directing all management of all air traffic control facilities to formally brief all air traffic controllers on the circumstances of the accident, and emphasise the need to request from flight crews clarification of unclear or ambiguous transmissions that convey a possible emergency situation or need for additional ATC assistance. B This might in fact be the MOST EFFECTIVE measure SISG 13 October 2003

What comes out of this comparison? SISG 13 October 2003

Same causes Same recommendation Recommendation not replicated Was not addressed at first? Wrong in the first place? New Recommendation Was not satisfactorily addressed at first? Missed in the second place? Missed in the first place? Was not implemented? Wrong in the second place? Situation has changed? Situation has changed? Same situation Nearly same outcome BUT (still) missing recommendation? SISG 13 October 2003

There seems to have a lot valuable dormant material • There to be no formal “system” to trace recommendations • There is no “formal procedure” to pick up lessons at collective level • Finally the importance of quality and depth of investigations should be emphasised SISG 13 October 2003

There are more examples: • Runway collisions/incursions • Mid-air collisions SISG 13 October 2003

Final word SISG 13 October 2003

To have an accident is unfortunate To have an accident and learn nothing from it is unforgivable (Flight Safety Digest) SISG 13 October 2003

Are lessons learned?